GW1--03177_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECO (GW-1.1 • For Internal Use Only. , •. '
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• 1.Well Co i Information: ,
. k •14.WATER ZONES . • •--
Wen Co for amattL: FROM TO DESCRIPTIOfr
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ft. ft.
NC Well Contractor CertifiationNumber,
15.OUTER CASING(for multi-cased wells)OR LINER(ifap liable) •
ntitAfyielir,-->:-, ,. C FROM TO DIAMETER T ICinVESS MATERLlL
Company Name I
ft. J is J
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1 /- • 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: (,� 8 3'�to FROM TO DIAMETER moms MATERIAL —
Lirl all applicable well construction permits(t e.WC,County,State,Variance.eta) 'f l ft G 3 ft. C'/,ln. 7 it /4.. —
3.Well Use(check well use): it - ! in /i7 /O'
Water Supply Well: • d7.SCREEN • !
• ❑Agritsultural ❑Mtmicipa]/Public FROM TO DIAMETER SLOT THICKNESS MATERIAL
ft.
.- in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
ft ft. in.'
Dlndustrial/Commercial ❑Residential•Water Supply(shared) •
❑Irri do 18•GROUT
4 ❑Wells>100,000 GPD FROM TO MA EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: ' 0 ft 23 A
• jl/�C7 / , ui�
❑Monitoring • ❑Recovery iti it Ail
Injection A
• Injection Well: fit MP no
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• ' ❑AquiferRecharge ❑Groundwater Remediation. !t ft. •
❑Aquifer Storage and Recovery • ❑SalinityBarrier 19.SAND/GRAVEL PACK(ifappliable)
FROM TO MATERIAL EMPIACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage - ' ft. R
❑Experimental Technology ❑Subsidence Control ' ft. ft.
• OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remaiics) PROM TO DESCRIPTION(color.hardneasovroek type,groin aceete)
ft ft
4.Date Well(s)Completed: 5..2—LI Well ID# ft •ft _ . -
5a.We lion: . 'o�' r. ( ..
Well Location:
ft. S ",i.,o.'L.P iL.:b n'
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• FacWity/Owne4Name FacilityID#(ifapplicable) •. ft. ft. �t� Y ,�u
jjj lU..-(1�-)ugh) C7 3 �'mh C aa• o R�( •:•ft 1n,0i „:4:�Pr:2,7 ��g
!�►� fG a a tJ�rG,a
ft.
Physical Address,City,ao Zip •
1 ft. • �".`„:`:/ice
VCj+ 21.REMARKSA
Couary �L� Parcel Identitication No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(*Ewell field,one lot/long is sufficient)
3 '21 ' 22.CertiS
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(n N 81 , 11 ' 2L ' w .4., . , ..
.6.Ls(are)the well(s): 'ermanent or ❑Temporary 017 i.0. Sigaat re fC ' Contractor Date
iXiNo By signing this fohn,Thereby certrfy that the well(s)war(vere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or If this is a repair,fill out known well construction information desplain the nature of the furls record has been provided to the wenO200 owner WellConstruction Standards and that a copy
•repair under#21 remarks section er on the back ofthisfonn.
23.Site diagram or additional well details:
• 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same. You may use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rdniarks Box).You may also attach additional drilled: panes if necessary.
24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: ' C. ,10 • (it.) .
Formultiple well,*list all depths Ifd�erent(emmpk-3@200'and 20100) Submit this OW-1 within 30 days of well completion per the following:
10.Static water level below top of casing. �-0 • (K) 24a. For All Wells: Original,form to Division of Water Resources (DWR),'
Ijwater level is above cacln&;rve l//�+ ` , Information Processing Unit,1617MSC,Raleigh,NC27699-1617 •
11.Borehole diameter:• r•(IXl Cm) 24b.For Injection Wells:Copy to DWR,Underground
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Program, MSC,Raleigh,NC 27699-1636 Injection Control(TUC)
12.Weft construction method: R 0 "!a hi — Cu- • -
(i.e auger,rotary.cable,direct push,etc.) ` 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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county environmental health department of the•
county where installed
• FOR WATER SUPPLY WELLS ONLY: • .
13a.Yield(gpm) 24�F r Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
Method of test • , gram,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: `�.1."/1 Amount: /Vit
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'Form GW 1' r r......._.__.: . — -